Dr. Smith: I have Dr. ***’s wife in a SomnoDent, if that helps. Is he aware of the protocol from the AASM that was issued 5 years ago?

“Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild to moderate OSA who prefer OAs to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or positional change.”

That’s from HIS organization!

clueless MD

Ask what his issues are.

If bite changes are his worry, tell them they change with CPAP also, and I can send you photos if needed. There is also a study from 2010 that shows craniofacial changes that occur after 2 years with CPAP. Very convincing.

If TMD is his worry, tell him you are well versed in handling these issues, and you have far fewer issues with the Somnodent, since it has more vertical freedom and you can dial the patient in carefully with .1mm adjustments

If he says they don’t work, see above protocol. There are numerous studies that prove otherwise.

If he says they can’t be titrated in a lab like PAP, that’s true, but we have portable monitoring to assess effectiveness as the appliance is being titrated.

If he says they cost too much, ask him why he doesn’t allow the patient to make that decision. Just send them over and let you handle that.

Follow up everything with “so, what do you do with your patients who do not tolerate CPAP? Most studies show these numbers run close to 50%, with the numbers being higher with mild to moderate patients, which, BTW, is what our appliances are really good at fixing. Do you just tell them to lose weight?” Dr. G: “Yes” You: “Really? How often do you follow them up to make sure they’re losing weight, and what success % are you seeing?”

If he says he sends them for surgery, say “Were you aware that your organization (AASM) says that’s backwards? In October of last year, they said that surgery is to be considered on patients “in whom oral appliances have been considered and found ineffective or undesirable”

One physician at a time, Dr. C. One at a time.

Dr. Smith: At the same time? Yes, it’s called combination therapy, and allows a CPAP user to have the pressure reduced to make it easier to use. They can also be used alternately when they are hunting, on airplanes, etc.. Of course, the right type of mask would need to be used, and preferably one of the nasal cone type that does not place any retrusive forces on the maxilla.

Another use for combination therapy is if you would like to prevent any potential occlusal (bite) changes with the mandibular advancement devices. If someone wears a MAD during the week, and CPAP on weekends, for example, they will get no bite changes.

Dr. Smith: No experience at all with childhood epilepsy and OSA. However, yes, I treat children with OSA…had one in today with great parents who both come with him at appointments. Mom was going in to hold his jaw forward for at least an hour every night to get him at least SOME restful sleep. Sleep centers are very comfortable with studies on children. Sleep walking shows no neurological effects or predispositions, so no worries there.

Children do not have to snore at all to have OSA, and when they do, the palatine tonsils are rarely (about 2% of the time) the cause. MUCH more common to have adenoidal obstruction (about 38% of the time, if memory serves), so his nasal obstruction is likely the source. I would get him in to see about the adenoids, then get a sleep study if this does not appear to be the problem. They put CPAPs on small children, but I doubt he will need that.

Dr. Smith: Eye infections are common due to minor mask leaks, and sinus infections can get serious real quick. If there is rhinorrhea, this is a sign of trouble. Obesity and OSA can predispose someone to cerebrospinal fluid leak. OSA can cause an increase in intracranial pressure, and this is exacerbated with nasal CPAP. The cribiform plate is very thin, and this excess pressure can expose defects. Bottom line – make sure they are monitored very closely.

Dr. Smith: I realize this is the least expensive screening method, and it’s better than nothing, as the oxygen saturation closely follows (as a rule) apneic events. However, this is misused by many health practitioners. I received a report from an ENT who used pulse oximetry, but with this specific patient, he desaturated to 77% and stayed under 90% for 42 minutes. The ENT stated that the patient needed no further study, did not need CPAP and that an oral appliance was the best thing. In my opinion, that is malpractice.

Dr. Smith: OK, here are some articles, Ross.
1. http://ajrccm.atsjournals.org/cgi/content/full/163/6/1294 (not compared to CPAP)
2. SLEEP 1995;18:501-10 Oral Appliances For The Treatment Of Snoring And Obstructive Sleep Apnea: A Review
Summary: This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee’s parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea.
3. http://findarticles.com/p/articles/mi_hb4345/is_3_35/ai_n29337679 (compares to CPAP)
4. http://www.journalsleep.org./ViewAbstract.aspx?pid=26465 Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review
Abstract:
We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.
Citation: Ferguson KA; Cartwright R; Rogers R et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP 2006;29(2): 244-262.

5. http://www.springerlink.com/content/j4w6r21256314131/fulltext.pdf Review of oral appliances for treatment of sleep-disordered breathing
Abstract Between 1982 and 2006, there were 89 distinct
publications dealing with oral appliance therapy involving a
total of 3,027 patients, which reported results of sleep studies
performed with and without the appliance. These studies,
which constitute a very heterogeneous group in terms of
methodology and patient population, are reviewed and the
results summarized. This review focused on the following
outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea
index or respiratory disturbance index), ability of oral
appliances to reduce snoring, effect of oral appliances on
daytime function, comparison of oral appliances with other
treatments (continuous positive airway pressure and surgery),
side effects, dental changes (overbite and overjet), and
long-term compliance